Workers’ Compensation Claims Management for Insurers

Workers’ Compensation Insurance

Workers’ compensation, commonly referred to as “workers’ comp,” is a government-mandated program that provides cash benefits, healthcare benefits, or both to workers who suffer injury or illness as a direct result of their jobs.

According to AIG (American International Group), Chubb Ltd., and Travelers Companies Inc., employers in the United States paid more than $62 billion in workers’ compensation claims in 2021. Approximately $30 billion of that amount went to compensating lost wages, and the remaining (nearly $2 billion) paid for the injured worker’s medical care.

Key Challenges for Workers' Compensation Insurers

Compliance Across Multiple States

In the U.S., workers’ compensation is handled primarily by the individual states and the required benefits vary greatly state by state. If you are handling claims across multiple states, you need to make sure that your adjusters accurately apply the regulations and required benefits of each individual state.

Efficient and Accurate Medical Bill Adjudication

Whether you outsource the adjudication of medical bills or processes them in house, it’s critical for your claims system to function as the financial source of truth for all claims-related payments.

HR Systems Integration

Once the initial report of a workers’ compensation claim is filed, all employee indicative information must be acquired and transcribed from the insured’s HR system into the claims system. Not only is this time consuming and prone to human entry errors, but it also exposes the company to risk of potential employee privacy breaches.

Omnichannel Communications

Your policyholders expect real-time communication across multiple channels (text, email, chat, phone, video) – corresponding just by snail mail or even email is no longer an option.  Unfortunately, most claims insurance technology is outdated and does not support omnichannel communications, leading to frustrated customers and unhappy adjusters.

The Benefits of Five Sigma's CMS for Workers' Comp Insurers

Our cloud-native data-driven claims management solution makes your claims processing simple and smart.

Automated Claims Submission

Our digital claims management solutions (CMS) provide:

  • All FNOL data received from the insurers/digital channels are embedded automatically into our workflows and ready for the next step in the process
  • Rapid system identification of claim types
  • Automated triage and adjuster assignment

Embedded Omnichannel Communications

Our CMS includes an API-level communication module that support all types of communications including: SMS, mail, voice video calls, and even WhatsApp. All claims-related communication is documented, stored and analyzed automatically.

Just-in-time Recommendations

Our systems flags coverage and liability issues and presents the adjuster with relevant information and investigative steps within the claims system.

Damage Assessment and Negotiation

The key to effectively negotiating a claim begins with accurate damage assessment. Our CMS includes a digital bodily injury evaluation module to itemize, assess and aggregate damages.

Monitoring and Management

Based on our advanced data modeling, we enable insurers to monitor your operations and receive actionable insights that will help you make strategic management decisions.

Replacing a Legacy Claims Management System

A U.S. western regional workers’ compensation carrier realized that they were experiencing an increase in LAE as their business grew and decided it was time to replace their legacy claims system to increase efficiencies.

They were looking for a modern claims system that was:

  • Customized for workers’ comp claims and could ensure state compliance for multiple states
  • Compatible and could be integrated with their HR and medical bill adjudication systems
  • Automated claims processing workflows to improve operational efficiencies

Learn how Five Sigma’s SaaS claims management solution not only dramatically improved operating efficiency but also enabled the claims system to serve as the claims financial source of truth for the organization.

Go live in weeks with the state-of-the-art claims management platform.